I reviewed each chart in detail as well as completed worksheets Please SM
Posted By: Jenny on 2008-01-09
In Reply to:
Subject: I reviewed each chart in detail as well as completed worksheets Please SM
in accordance with 1997 HCFA Guidelines for-new-um documentation. This is a letter sent to a health plan regarding a recent office chart audit. Any help would be appreciated.
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Nurse's notes reviewed or nurses notes reviewed? nm
Subject: Nurse's notes reviewed or nurses notes reviewed? nm
x
more detail...
Subject: more detail...
Sorry, I should have mentioned this is an endoscopic sinus surgery, and the surgeon is creating a s/l Parson's window. Thanks!
Oops, more detail
Subject: Oops, more detail
Went back to my note and duh, there was more context in the last reference. Maybe should go to bed:
"... with PEG placement, currently under the care of speech therapy"
So I guess she actually ran good things together! 
Thanks again!
SG
procedure and detail
Subject: procedure and detail
s/ phofatomy
stainless steel crown and oposite.
Can you explain this in a little more detail? nm
Subject: Can you explain this in a little more detail? nm
s
Remainder was completed.
Subject: Remainder was completed.
You are absolutely right. The word, "remainder" is the subject ("of the forms is just a prepositional phrase"), and the verb/adverb should always go with the subject, not its modifier(s).
PROMPT CHART??
Subject: PROMPT CHART??
New to doing ER reports and Dr. dictates refer to PROMPT chart for rest of patient's records. Is this correct? Thanks in advance.
Chart Note
Subject: Chart Note
On lab work do I put it in right order (i.e. EKG after white count and hemoglobin) or just do as dictated?
Can find the abbreviation ANL everywhere on Occupational Therapy sites and they go into great detail
Subject: Can find the abbreviation ANL everywhere on Occupational Therapy sites and they go into great detail about what it entails, but nothing states exactly what the abbreviation stands for... see below
from www.activehomerehab.com
Functional Retraining Programs: Based on functional problems identified in the in-home ANL assessment, the occupational therapist will teach the client and their caregivers, strategies to increase independence with functional tasks such as dressing, bathing and meal preparation. Homemaking retraining programs may also be warranted in which education and training are provided regarding pacing, work simplification, proper body mechanics and use of assistive devices (if necessary), to facilitate return to pre-accident homemaking activities
Otherwise, the remainder of the forms were completed
Subject: Otherwise, the remainder of the forms were completed
////
RE: Otherwise, the remainder of the forms were completed
Subject: RE: Otherwise, the remainder of the forms were completed
Yes.
with completed s/l Circ in 1992...
Subject: with completed s/l Circ in 1992...
Hepatitis B series with completed s/l Circ in 1992 without subsequent titers drawn.
Thank you,
Deborah
laminectomy was completed with s/l 3 and 4 Garrisons?
Subject: laminectomy was completed with s/l 3 and 4 Garrisons?
Venogram completed on "Semi"
Subject: Venogram completed on "Semi"
Would SEMI be an acronym for special electromagnetic interference ?
I checked wtih the original chart
Subject: I checked wtih the original chart
that I typed where the doctor stated that he was going to do an FNA and it was on the thyroid. I had already sent my charts, but I copied and pasted another with the work spelled colloid and an explanation and then sent that. Thanks so much.
s/l Labo and McCunning correction chart (sm)
Subject: s/l Labo and McCunning correction chart (sm)
Doc says: "I believe [patient] will probably need to have an epiphysiodesis done. I will have to look at 'Labo and McCunning' Correction Chart to decide when it is most appropriate to that."
Was completed. Remainder is the subject here and is singular not pleural. nm
Subject: Was completed. Remainder is the subject here and is singular not pleural. nm
x
Pulled chart. Definitely Celexa. Good thinking!
Subject: Pulled chart. Definitely Celexa. Good thinking!
Likely face sheet..first page of chart which usually contains known diagnoses. NM
Subject: Likely face sheet..first page of chart which usually contains known diagnoses. NM
14 point review of systems was done s/l weighted, dated and placed in chart. Is that right?
Subject: 14 point review of systems was done s/l weighted, dated and placed in chart. Is that right?
n/t
s/l "cyberun" Maybe some type of chart record? Dialysis patient sm
Subject: s/l "cyberun" Maybe some type of chart record? Dialysis patient sm
States: "Review of report in ____ suggests..." Again later in dictation: "Although this is not charted in ____. "
reviewed nm
Subject: reviewed nm
xx
? term "cyber" in relation to "computer/electronic chart" documentation. (sm)
Subject: ? term "cyber" in relation to "computer/electronic chart" documentation. (sm)
This is just a guess as I am not "computer savvy" in regards to tech terms.
Pt with cervical spine pain. She has completed her CT myelogram as well as s/l tunnel gram.?? tia
Subject: Pt with cervical spine pain. She has completed her CT myelogram as well as s/l tunnel gram.?? tia
48-hour pH test completed and extensive *physiatry* to view the findings which demonstrated
Subject: 48-hour pH test completed and extensive *physiatry* to view the findings which demonstrated
She states that she is unable to eat, continues to lose weight, and is having bouts of vomiting. She did have her 48-hour pH test completed and extensive *physiatry* to view the findings which demonstrated that on the first night when she had vomited after her procedure, there were some episodes of breakthrough acid; however, the following day when she was tolerating a diet and had her AcipHex, her pH was well controlled, above a pH of 4, essentially the entire time. Therefore, I discussed with the patient that her chest burning does not appear to be correlated with breakthrough acid of any significant degree and suggests the possibility that a lot of her chest pain and burning may be related to her anxiety and depression.
how about completed "circuit" in 1992 nm (series-parallel circuit for treatment of HepB) nm
Subject: how about completed "circuit" in 1992 nm (series-parallel circuit for treatment of HepB) nm
ob/gyn report ...s/l braided was reviewed with her.
Subject: ob/gyn report ...s/l braided was reviewed with her.
This was under plan. I don't know if it has to do with the birth control pill they are instructing her about.
All other systems are reviewed and are negative
Subject: All other systems are reviewed and are negative
okay i need help. is he saying....."all other systems are reviewed and are negative" or "all of the systems are reviewed and are negative"???????? it is under the heading, REVIEW OF SYSTEMS.
Doc reviewed the pt's s/l "SSP PET" scan. How to type correctly? nm
Subject: Doc reviewed the pt's s/l "SSP PET" scan. How to type correctly? nm
X-rays reviewed which show a bone abnormality please sm
Subject: X-rays reviewed which show a bone abnormality please sm
in the distal femur laterally, most likely **synofiying** or ossifying fibroma. ?? thanks
reviewed pathology of *inter_____* core biopsy??? thanks. nm
Subject: reviewed pathology of *inter_____* core biopsy??? thanks. nm
nm
MRI is reviewed of the right elbow that shows moderate high signal at the proximal please sm
Subject: MRI is reviewed of the right elbow that shows moderate high signal at the proximal please sm
_______ of the ulnar collateral ligament complex compatible with tendinosis without tear. Thanks
MRI is reviewed whch shows s/l intrasepsis tear supraspinatus tendon. nm
Subject: MRI is reviewed whch shows s/l intrasepsis tear supraspinatus tendon. nm
MRI is reviewed which shows osteochondral defect in the s/l capetome and bone contusion of the sm
Subject: MRI is reviewed which shows osteochondral defect in the s/l capetome and bone contusion of the sm
radial head. Thanks
s/l I reviewed the brain MRI recently performed: there is a septum delluzidium cavum, a normal -sm
Subject: s/l I reviewed the brain MRI recently performed: there is a septum delluzidium cavum, a normal -sm
anatomic varient???? Thanks.
X-rays reviewed that show a lucent line around the humeral component bone please sm
Subject: X-rays reviewed that show a lucent line around the humeral component bone please sm
cement s/l dith-ro-face. The ulnar component appears to be well-fixed. Thanks!!
X-rays reviewed that show questionable volar **assisted* scaphoid fracture. Thanks
Subject: X-rays reviewed that show questionable volar **assisted* scaphoid fracture. Thanks
X-rays reviewed that show complete healing to the s/l symvasis pubis fracture. TIA
Subject: X-rays reviewed that show complete healing to the s/l symvasis pubis fracture. TIA
X-rays reviewed that show maintenance of alignment and fixation, and progressive signs of healing sm
Subject: X-rays reviewed that show maintenance of alignment and fixation, and progressive signs of healing sm
now on three out of four s/l cordices. Thanks!
Bone scan is reviewed dated 03/06/09 which shows increased activity to the pubic bones at the sm
Subject: Bone scan is reviewed dated 03/06/09 which shows increased activity to the pubic bones at the sm
s/l synthesis. Thanks!
I reviewed x-rays today. They show some s/l white blush of healing along the medial tibial plateau.
Subject: I reviewed x-rays today. They show some s/l white blush of healing along the medial tibial plateau.
TIA :-)
Lots of Detail for Lots of Help!
Subject: Lots of Detail for Lots of Help!
Okay, I'm transcribing a SOAP note and this word that I'm trying to figure out is under the ASSESSMENT AND PLAN part. She says the word three times and I am now thinking she is saying something like "number next or number next is." What do you think?
(Normonaxis) Anemia may be caused from a recent epistaxis. He will start an iron pill daily over the counter called Fergon. Next visit we will check a hemoglobin, iron studies. (Normonax) He was in for right shoulder pain in the past. This was resolved. (Normonax) Recent qualm was treated with doxycycline.
Also, I was told to transcribe this using a straight SOAP format, but the doctor dictates things like "Review of Systems" and "Exam." I didn't think those headings or subheadings were in a SOAP format. She never dictates "Subjective" or "Objective," only "Assessment And Plan" as one heading towards the end of the report. Any advice?
Also reviewed were bone scan, white cell scan and s/l solfar coag scan. Thanks
Subject: Also reviewed were bone scan, white cell scan and s/l solfar coag scan. Thanks
Might be Angular Deformity correction chart taken from the Angular Deformity
Subject: Might be Angular Deformity correction chart taken from the Angular Deformity
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